We wish to thank our correspondents for their numerous and constructive responses, which further underline the importance of not only the diagnosis but also the multifaceted therapy of osteoarthritis of the knee. Among our other intentions, we also wanted to shed a critical light on the pathology that is osteoarthritis of the knee. Unquestionably, however, the details of the different treatments for osteoarthritis of the knee are too numerous and far reaching, and vastly exceed the scope of such an article. We aimed to provide a rough overview and to address learning objectives, such as recognizing risk factors for the development of osteoarthritis of the knee, diagnostic options, preventive measures, and joint sparing treatment.
Professor Lindner laments the omission of knee replacement surgery, the standard treatment for severe osteoarthritis of the knee. We remind readers of the learning objectives. Figure 2 in our article provides a clear treatment algorithm for patients with clinically relevant osteoarthritis of the knee. In our opinion it is obvious that in pronounced medial stage IV osteoarthritis of the knee, such as is shown in Figure 1, an endoprosthetic knee replacement is the treatment of choice.
Dr Rüdinger reminds us that acupuncture for osteoarthritis of the knee is covered by the statutory health insurance companies nationwide. He mentions the GERAC study (published by Ruhr University in Bochum), which summarizes the effects of acupuncture: “10 to 15 acupuncture sessions, verum as well as sham, alleviated symptoms more effectively than conventional therapy.” We need to point out in this context that the inclusion criteria considered Kellgren stage 2 or 3 osteoarthritis. We also emphasized that the notable overall effects in favor of acupuncture on the one hand and the lacking superiority (except for a lacking indication) compared with sham acupuncture give rise to a wide range of interpretations. Ultimately, this needs to be discussed with the patient.
The later study by Kirkley et al (1) comparing the efficacy of optimized conservative therapy with a combination of conservative therapy plus arthroscopy, as pointed out by Professor Michalsen, found no difference. Arthroscopy is therefore not superior to conservative treatment approaches.
One correspondent mentions leech therapy (2). Our article did not aim to provide details of individual conservative therapeutic options. According to the EULAR recommendations (3), paracetamol is the first-line medication of choice. Dr Weiss rightly points out that paracetamol is not necessarily effective in alleviating arthritis pain. However, the non-steroidal anti-inflammatory drugs (NSAIDs) are also included in the EULAR analgesic/therapeutic ladder. Low-dose radiotherapy for painful Kellgren stage 2–3 osteoarthritis of the knee is certainly indicated, as mentioned by Dr Mücke. We agree with the working group for tissue regeneration and tissue replacement within the German Society of Trauma Surgery (DGU) and the German Society for Orthopaedics and Orthopaedics surgery, that the 2004 recommendations for indications and methods for the different biological reconstructive techniques (microfracturing, mosaicplasty, autologous chondrocyte transplantation [ACT]) are tried and tested and should continue to be used in everyday clinical practice.
PD Dr. med. Joern W.-P. Michael
Klinik und Poliklinik für Orthopädie und Unfallchirurgie
Universität zu Köln
50931 Köln, Germany
Conflict of interest statement
The author declares that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.
|1.||Kirkley A, Birmingham TB, Litchfiled RB, et al.: A randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM 2008; 359: 1097–107. MEDLINE|
|2.||Michalsen A, Roth M (eds.): Blutegeltherapie. 2nd edition. Stuttgart: Haug 2009.|
|3.||Pendelton AN, Arden N, Dougados M, et al.: EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCICIT). Ann Rheum Dis Dec 2000; 59: 936–44. MEDLINE|
|4.||Michael JWP, Schlüter-Brust KU, Eysel P: The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee [Epidemiologie, Ätiologie, Diagnostik und Therapie der Gonarthrose]. Dtsch Arztebl Int 2010; 107(9): 152–62. VOLLTEXT|